(adrc) - oregon · can’t afford to pay these costs? they might qualify for financial help – •...

July 13, 2016

Aging &

Disabilities

Resource

Connection

(ADRC)

Training

Oregon Senior Health Insurance Benefits Assistance July 2016

Overview of Medicare

Federal Low Income Subsidy (LIS)

State help with paying Medicare costs

Referring to Oregon Medicare Savings Connect (OMSC)

Limited Income NET

Oregon Prescription Drug Program (OPDP)

Other assistance programs

Senior Health Insurance Benefits Assistance

ADRC key searches

Job aids


Medicare starts at age 65 or after 24 months of SSDI

Can delay enrollment without penalty if covered by an Employee Group Health Plan (EGHP) through active work (self or spouse) However, Medicare is primary if EGHP has less than 20

employees in group health plan

Part A is inpatient hospital insurance covering room, board, general nursing and supplies, and drugs

Part B is hospital observation or outpatient stays, physician’s fees, labs, medical equipment, preventive services, etc.

Part C is private contracted Medicare called Medicare Advantage plans (health only or health + drug)

Part D is stand-alone prescription drug insurance


Part A – Covers most costs for:

Part B – Covers 80% of approved costs for:

Part D

Prescription Coverage

Original Medicare

Deductible

and co-ins

Premium +

20% after

deductible

Patient pays

• Hospital • Home Health Care

• Hospice • Skilled Nursing Services

• Doctors’ services • Medical Equipment

• Lab work • Emergencies, etc.

Premium + deductible +

co-pays / co-insurance


Part A – Pays most

Part B – Pays 80%

Part D –

Pays some

Deduct. +

Co-Insur

Original Medicare

How to pay

the premiums,

deductibles

and remaining

cost shares?

Premium +

20% after

deductible

Premium +

deductible +

cost share


Original Medicare How to pay the cost shares?

A “MEDIGAP” policy is one way to cover the

costs that Original Medicare doesn’t pay.

Secondary

coverage

for

hospital

and

medical

expenses

Part A – Pays most

Part B – Pays 80%

Deduct. +

Co-pays

Premium +

20% after

deductible

M

E

D

I

G

A

P

Medigap does not cover prescriptions. Separate insurance, such

as a Part D plan, must be added for this benefit.


Part A – Pays 80%

Part B – Pays 80%

Deduct.

+

co-pays

Deduct.

+

20 %

Original Medicare How to pay the cost shares?

• Covers hospital &

medical at plans’

co-pay / co-ins costs

• Can have extra

benefits like vision,

dental or fitness.

Medicare Advantage can also

include Rx coverage

Medicare Advantage

Part D –

Pays some

Prem +

deduct +

cost share

So, what happens when people

can’t afford to pay these costs?

They might qualify for financial help –

• Medicare Savings Programs to pay, at

minimum, the Part B premium

• Limited Income Subsidy (LIS or “Extra

Help”) to pay the Part D premium,

deductible, reduced co-pays, and some or all

of the “donut hole”.


Federal program that allows eligible individuals or couples to qualify for prescription drug insurancepremium subsidy and lowercost share at pharmacy

Eligibility determined by Application to Social Security

Deemed eligible if receiving state assistance

Applying online is the most expeditious

Determinations typically within 3-4 weeks

Oregon Medicare Savings Connect and SHIBA will process online applications


*Residence and car do not count as assets. Must meet both the

income and asset limits to qualify.


State assistance with the costs associated with

Medicare

Called Qualified Medicare Beneficiary (QMB) at

state offices

QMB – BAS is the highest level of assistance covering

the Part B monthly premium, deductibles and co-

insurances

QMB - SMB covers only the Part B

monthly premium

QMB - SMF covers only the Part B

monthly premium

Resources are NO LONGER COUNTED


Medicare Savings Program is a state Medicaid program that pays the Medicare

Part B premium. If eligible for QMB (100% FPL), the program also pays the

deductibles and cost shares associated with Medicare services.


Funded by a grant from the Medicare

Improvement for Patients and Providers

Act (MIPPA)

Call 855-447-0155


Toll free access to help withbenefit programs

Live coverage M-F, 8-5; 24 hours voice mail available

Provides application assistancefor the federal LIS program

Provides application assistance for the MSP (QMB) program Forwards referrals to local APD offices

Provides referrals to community resources by linking callers to AAA and ARDC offices

Refers callers to local SHIBA offices for Medicare choice counseling


Provides statewide outreach and education

about LIS and MSP

On request, can send outreach materials or

partner in events with your agency

Contact Ryan Francario

(503) 988-8551

1-855-447-0155

[email protected]


mailto:[email protected]

Allows those qualifying for the Limited

Income Subsidy to purchase meds at the

subsidy rate

Bridges coverage until a prescription drug

plan is chosen or assigned

Requires verification of eligibility with best

available evidence (BAE)

Letter of subsidy award from SSA

Letter of financial assistance from APD

FAX BAE to LI NET within 21 days

877-210-5592


Free!

Available to all Oregonians regardless of age,

income, employment or health.

Bulk prescription drug purchase in

partnership with the state of Washington

Provides up to 16 percent discount on brand

name and 69 percent discount on generic

medications

Register at www.OPDP.org


http://www.opdp.org/

www.NeedyMeds.org

A national non-profit organization that maintains

a website of free information on programs that

help people who can't afford medications and

healthcare costs

www.SIRUM.org

SIRUM saves peoples’ lives by allowing health

facilities, manufacturers, wholesalers, and

pharmacies to donate unused medicine rather

than destroy it.

We provide medications to those who need but

cannot afford them for a small co-pay


http://www.needymeds.org/

http://www.sirum.org/

Senior Health Insurance Benefits Assistance

(SHIBA) is the State Health Insurance

Information Program (SHIP) for Oregon

Funded by a grant from ACL with additional

support from the Div of Financial Regulation

Provides insurance choice counseling and

advocacy for Medicare beneficiaries, their

families and/or caregivers


Provides application assistance for the

federal Low Income Subsidy

Refers to local APD offices when applicable

Provides education and outreach through

public presentations

Assists with fraud prevention and reporting

17 local sponsors and 280 certified

counselors statewide

For more information on SHIBA go to:

www.OregonSHIBA.org


http://www.oregonshiba.org/

Washington County

Washington County's

Benefits Enrollment Center

is a one-stop-benefits-shop

Call 503-846-3060 for

Intake & Referral –or-

1-855-ORE-ADRC (673-2372) and ask for the

Benefits Enrollment Center

Other Counties

Check to see if there are similar benefit hubs

in your local county


Do you know where to find these resources on

ADRC?

Oregon Medicare Savings Connect

SHIBA

Key word searches

LIS

MSP

Medicare

Extra Help

Prescription Help


(adrc) - oregon · can’t afford to pay these costs? they might qualify for financial help – •...

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